Author Question: Brenda is a student nurse who is working on a long-term rehabilitation unit. She is providing care ... (Read 46 times)

lindiwe · **on:** Jul 22, 2018

Brenda is a student nurse who is working on a long-term rehabilitation unit. She is providing care for Mrs. Reynolds, a 46-year-old woman who was the victim of a violent crime and suffered a head injury. Mrs.

Reynolds has an endotracheal tube which is secured with tape. The tape is crusted with dried secretions. Brenda is has been asked to provide personal hygiene for Mrs. Reynolds and needs to replace the tape. What is the best way for Brenda to remove the tape? A. Soak it with warm moist washcloths.
B. Pull it gently away from the skin.
C. Saturate it with denatured alcohol.
D. Soak it with adhesive remover.

Question 2

You have just completed a home visit on a 12-year-old quadriplegic girl. The patient was admitted with pressure ulcers to bilateral ankles.

You evaluate the pressure ulcers have healed when there is no evidence of which of the following? Select all that apply. A. Redness
B. Pallor
C. Moisture
D. Blisters

todom5090 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
When patients have nasogastric, feeding, or endotracheal tubes inserted through the nose, change the tape anchoring the tube at least once a day. When the tape becomes moist from nasal secre-tions, the skin and mucosa can easily become macerated (softened by soaking). Friction from a tube causes tissue injury. Anchor tubing correctly with tape or fixative devices to minimize ten-sion or friction on the nares.

Answer to Question 2

A, B
Damage of superficial skin layers is indicative of injury. Blisters suggest the top layer of skin is pulled or rubbed.